Optimal Intermittent Administration Interval of Abaloparatide for Bone Morphogenetic Protein-Induced Bone Formation in a Rat Spinal Fusion Model.

Both bone morphogenetic protein 2 (BMP-2) and abaloparatide are used to promote bone formation. However, there is no consensus about their optimal administration. We investigated the optimal administration theory for the pairing of BMP-2 and abaloparatide in a rat spinal fusion model. Group I was only implanted in carriers and saline. Carriers with 3 µg of recombinant human BMP-2 (rhBMP-2) were implanted in other groups. Abaloparatide injections were administered three times a week for group III (for a total amount of 120 µg/kg in a week) and six times a week for group IV (for a total amount of 120 µg/kg in a week) after surgery. They were euthanized 8 weeks after the surgery, and we explanted their spines at that time. We assessed them using manual palpation tests, radiography, high-resolution micro-computed tomography (micro-CT), and histological analysis. We also analyzed serum bone metabolism markers. The fusion rate in Groups III and IV was higher than in Group I, referring to the manual palpation tests. Groups III and IV recorded greater radiographic scores than those in Groups I and II, too. Micro-CT analysis showed that Tbs. Sp in Groups III and IV was significantly lower than in Group I. Tb. N in Group IV was significantly higher than in Group I. Serum marker analysis showed that bone formation markers were higher in Groups III and IV than in Group I. On the other hand, bone resorption markers were lower in Group IV than in Group I. A histological analysis showed enhanced trabecular bone osteogenesis in Group IV. Frequent administration of abaloparatide may be suitable for the thickening of trabecular bone structure and the enhancement of osteogenesis in a rat spinal fusion model using BMP-2 in insufficient doses.

Effectiveness of gelatin matrix with human thrombin for reducing blood loss in palliative decompressive surgery with posterior spinal fusion for metastatic spinal tumors.

BACKGROUND: This study aimed to investigate the effect of gelatin matrix with human thrombin (GMHT) on blood loss and survival time in patients with metastatic spinal tumors treated with palliative decompression surgery with posterior spinal fusion. METHODS: We retrospectively reviewed 67 consecutive patients with metastatic spinal tumors who underwent palliative decompression surgery with posterior spinal fusion. We compared patients in whom GMHT was not used during surgery with those in whom GMHT was used. The following baseline characteristics were evaluated: age, height, weight, sex, metastatic tumor diagnosis, medical history, use of antiplatelet drug, use of anticoagulant drug, use of NSAIDs, smoking, preoperative PLT value, preoperative APTT, preoperative PT-INR, Karnofsky Performance Status score, Charlson comorbidities index score, the percentage of patients who received perioperative chemotherapy, main tumor level, Frankel category, revised Tokuhashi score, spinal instability neoplastic score (SINS), number of fusion segments, operation time, intraoperative blood loss, drainage blood loss, red blood cell transfusion, hemoglobin level, total protein (TP), albumin values, total blood loss (TBL), hidden blood loss, postoperative bed rest and postoperative survival time. Perioperative complications were assessed. RESULTS: Age, height, weight, sex, metastatic tumor diagnosis, medical history, use of antiplatelet drug, use of anticoagulant drug, use of NSAIDs, smoking, preoperative PLT value, preoperative APTT, preoperative PT-INR, CCI score, main level of tumors, SINS score, preoperative Tokuhashi score and number of fusion segments did not differ significantly between the two groups. Operation time, intraoperative blood loss, postoperative drainage blood loss, and TBL were significantly decreased in the group with GMHT than in the group without GMHT. The total number of perioperative complications was significantly lesser in the group with GMHT than in the group without GMHT. The median postoperative survival time was significantly longer in the GMHT group than in the group without GMHT. CONCLUSION: GMHT should be considered a valid option for the treatment of patients with metastatic spinal tumors with a short life expectancy.

Dome impaction classification in acetabular fractures: Identifying atypical dome impactions with absence of the gull sign: A retrospective descriptive study.

We aimed to describe variations of dome impaction fractures and their characteristics using a new classification system, to explore the relationship between dome impaction and the gull sign. The present study was a retrospective descriptive study. All 104 cases of acetabular fracture that were treated in our institution from 2013 to 2022 were enrolled. Of these, 22 had dome impaction fractures. The primary outcome variable was to describe the variations and characteristics of dome impaction fractures. They were classified into 3 major subgroups based on reconstructed axial, coronal, and sagittal computed tomography findings: anteromedial, superomedial (SM), and posteromedial. The secondary outcome variable was to explore the relationship between dome impaction on computed tomography findings and the gull sign on plain radiographs. There were 4 cases of anteromedial (18.2%), 13 of SM (59.1%), and 5 of posteromedial (22.7%). There were 15 cases (68.2%) with the gull sign and 7 cases (31.8%) without the gull sign on plain radiographs. Twelve of fifteen cases (80.0%) with the gull sign had dome impaction fractures of the SM type. We found a variety of patterns of dome impaction fracture. Surgeons should be aware of atypical dome impactions not showing the gull sign.

Efficacy of gelatin-thrombin matrix sealants for blood loss in single-level transforaminal lumbar interbody fusion.

Although gelatin-thrombin matrix sealants have been used successfully in other surgery types, their effect on reducing blood loss during single-level transforaminal lumbar interbody fusion is unclear. We thus examined the efficacy of gelatin-thrombin matrix sealants for reducing blood loss during such surgery. We analyzed 102 patients who underwent single-level transforaminal lumbar interbody fusion for lumbar degenerative disease. We compared body mass index, surgical time, intraoperative blood loss, postoperative blood loss, true total blood loss, hidden blood loss, the proportion of blood transfusion, blood pressure pre- and post-surgery (systolic and diastolic), and pre-and post-surgery laboratory data (hemoglobin, hematocrit, platelets, prothrombin time, activated partial thromboplastin time, and D-dimer) between patients in whom gelatin-thrombin matrix sealants were (GTMS group) or were not (control group) used during surgery. One-week postoperative epidural hematoma size was measured using magnetic resonance imaging. The GTMS and control groups included 54 (24 males and 30 females) and 48 patients (19 males and 29 females). Intraoperative, true total, and hidden blood loss; epidural hematoma size; and hospitalization duration were significantly lower in the GTMS than in the control group. Intraoperative blood loss correlated with surgical time (R = 0.523, P = .001), body mass index (R = 0.221, P = .036), and the amount of gelatin-thrombin matrix sealant used (r = -0.313, P = .002). In multivariate linear regression analysis using intraoperative blood loss as the dependent variable, surgical time (standardization coefficient 0.516, P = .001) and amount of gelatin-thrombin matrix sealant used (standardization coefficient -0.220, P = .032) were independently related factors. In our study, the GTMS group had significantly less intraoperative true total and hidden blood loss than did the control group. Thus, use of gelatin-thrombin matrix sealants reduce perioperative blood loss in transforaminal lumbar interbody fusion.

Analysis of accuracy of pedicle screw placement in dysplastic pedicles in adolescent idiopathic scoliosis using the pedicle expansion technique with CT-based navigation.

BACKGROUND: This study aimed to study the accuracy of pedicle screw (PS) insertion into dysplastic pedicles in adolescent idiopathic scoliosis (AIS) comparing cannulated screw using the pedicle expansion technique (PET) versus conventional technique. METHODS: Forty-two AIS patients with 766 PSs were evaluated. In total, 236 screws were inserted into dysplastic pedicles: 138 and 98 screws were inserted using the PET (PET group) and standard technique (conventional group), respectively. Both methods used CT-based navigation to determine the insertion point. In the PET, a rigid ball tip feeler was tapped with a mallet to create an insertion route, a guide wire was passed through the tap, the pedicle was enlarged, and then a cannulated PS with a diameter of 4.35 mm was inserted. Postoperative CT was used to compare the accuracy of PS insertion. RESULTS: In total, 23/236 (9.7%) perforations occurred. Regarding overall perforation, there were six (4.3%) and 17 (17.3%) cases in the PET and conventional group, respectively (P = 0.008). In terms of medial perforation, the PET group (n = 2, 1.4%) was significantly better than the conventional group (n = 7, 7.1%) (P = 0.021). In terms of lateral perforation, the PET group (n = 4, 2.9%) was significantly better than conventional group (n = 10, 10.2%) (P = 0.030). Only grade 1 perforation had occurred in the PET group, whereas grades 2 and 3 perforation occurred in the conventional group. CONCLUSION: Use of the PET with CT-based navigation significantly increased the accuracy and safety of PS insertion in dysplastic pedicles in AIS.

Relationship between K-line distance and surgical outcome in cases of laminoplasty for cervical ossification of the posterior longitudinal ligament.

Although previous studies indicate that changes in cervical alignment after laminoplasty and dynamic factors influence surgical outcomes of cervical ossification of the posterior longitudinal ligament (OPLL), the relationship between the surgical outcomes, the distance between the kyphosis-line (K-line) and OPLL, and dynamic factors have not yet been quantitatively evaluated. The purpose of the present study was to analyze the relationship between ΔK-line distance and surgical outcomes in cases of laminoplasty for OPLL of the cervical spine. We retrospectively reviewed 46 consecutive patients (33 men and 13 women) with cervical OPLL who underwent laminoplasty. "K-line distance" was measured as the minimum interval between the K-line and OPLL on lateral radiographs. The following factors were analyzed: K-line distance in neutral, flexion, and extension neck positions, ΔK-line distance, preoperative C2-7 range of motion (ROM), preoperative segmental ROM, preoperative C2-7 lordotic angle, occupying ratio of the OPLL, disease duration, preoperative and postoperative Japanese Orthopaedic Association (JOA) score, and recovery rate. Patients were divided into flexion K-line (+) and flexion K-line (-) groups. We then analyzed the influence of the K-line distance on surgical outcomes and conducted multivariate analysis to analyze the factors affecting surgical outcomes. The JOA score recovery rate in the flexion K-line (-) group was significantly lower than that in the flexion K-line (+) group (P = .024). The ΔK-line distance was significantly negatively correlated with the JOA score recovery rate (r = -0.531, P < .001). Additionally, multivariate analysis showed that ΔK-line distance (OR = -2.143, P = .015) was negatively correlated with the JOA score recovery rate. The ΔK-line distance is considered useful for the quantitative evaluation of dynamic factors and static compression factors due to OPLL through the measurement of dynamic radiographic images.

Analysis of rotational deformity correction by lateral lumbar interbody fusion with two-staged anterior-posterior combined corrective fusion surgery for adult degenerative kyphoscoliosis.

The present study is retrospective analysis of consecutively collected data. Lateral lumber interbody fusion (LLIF) is widely used in cases of adult spinal deformities. However, the corrective effects of LLIF cage insertion on the vertebral rotation deformity in the axial plane and the individual effects of LLIF and direct vertebral rotation (DVR) on rotational correction are unclear. To individually examine the corrective effects of LLIF and posterior corrective fusion surgery with direct DVR on vertebral rotation deformities in adult degenerative kyphoscoliosis. We analyzed 21 patients (5 males and 16 females) who underwent two-staged anterior-posterior combined corrective fusion surgery for adult degenerative kyphoscoliosis. Surgical time, blood loss, facet joint osteoarthritis (OA) grade, disc degeneration, cage height, vertebral rotational angle, and various X-ray parameters were investigated as evaluation items. The X-ray parameters showed significant postoperative improvements. The mean vertebral rotation angle was 6.4°â€…±â€…5.2° preoperatively, 3.5°â€…±â€…3.3° after LLIF (P = .014, vs preoperative), and 1.6°â€…±â€…1.7° after posterior corrective fusion surgery with DVR (P = .011, vs preoperative). Correlation analysis between the vertebral rotation angle and various measured values revealed that the vertebral rotation angle after LLIF was correlated with the cage height (r = -0.46, P = .032). The vertebral rotation angle after DVR was correlated with the facet joint OA grade (r = -0.49, P = .018) and the wedge angle after posterior corrective fusion surgery with DVR (R = 0.57, P = .006). We conclude that the effects of rotational deformity correction with LLIF cage insertion and additional posterior corrective fixation with DVR can be useful for correcting vertebral rotation deformities.

Analysis of treatment effect with teriparatide on device-related vertebral osteopenia after lumbar spinal interbody fusion using Hounsfield unit values: A retrospective cohort study.

The aim of the present study was to investigate the effect of teriparatide on device-related vertebral osteopenia after single lumbar spinal interbody fusion and compare osteopenia in fused and nonfused spinal segments using Hounsfield unit (HU) values. The present study was a retrospective cohort study. We reviewed 68 consecutive patients (28 men and 40 women) who underwent single-segment (L4-5) transforaminal lumbar interbody fusion with cage and pedicle screw fixation. The patients were divided into 2 groups according to whether they were treated with teriparatide (teriparatide and nonmedication groups). The primary outcome measure was HU values measured on computed tomography images from each L1 to S1 vertebral body12-month postoperatively. Secondary outcome measures were femoral neck bone mineral density (BMD), T-score, osseous union, and clinical outcomes using the Japanese Orthopedic Association scoring system 12-month postoperatively. There were significant decreases in HU values of lumbar vertebral bodies at all levels and BMD and T-score values obtained using dual-energy X-ray absorptiometry of the femur between preoperative and postoperative 12-month computed tomography in the nonmedication group (P < .05). On the other hand, there were no significant differences between properative and postoperative 12-month HU values of each lumbar vertebral body and BMD values of the femur in the teriparatide group. Osseous fusion scores in the teriparatide group were significantly better than those in the nonmedication group. There were no significant differences in postoperative Japanese Orthopedic Association scores between the 2 groups. Administration of teriparatide during the perioperative period may prevent bone loss associated with spinal fusion surgery.

Analysis of the risk factors for increasing cervical sagittal vertical axis after cervical laminoplasty for cervical spondylotic myelopathy.

INTRODUCTION: The cervical sagittal vertical axis (cSVA) as another aspect of cervical alignment been recognized as one of the important factors affecting the pain and disability outcomes of cervical spine surgery. The purpose of the present study was to analyze the risk factors for increasing cSVA after cervical laminoplasty for cervical spondylotic myelopathy (CSM). MATERIALS AND METHODS: This retrospective study included 110 consecutive patients (68 males and 42 females, average age 72.6 years) who underwent laminoplasty for CSM between January 2007 and June 2018. We recorded the operative time, blood loss, Japanese Orthopaedic Association (JOA) score and the recovery rate. Radiological measurements were performed to analyze the following parameters: pre- and 1-year postoperative McGregor's slope (McGS), occiput to C2 Cobb angle (O-C2 angle), C2-C7 Cobb angle (C2-7 angle), T1-slope (T1S), C2-7 SVA (cSVA) and calculated the change (Δ). Patients were divided into two groups according to whether ΔcSVA was positive or negative. We also used Spearman's correlation coefficient and multiple regression analysis. RESULTS: ΔC2-7 angle, ΔT1S-preoperative C2-7 angle, ΔO-C2 angle were different between the two groups significantly. Correlation analysis between the ΔcSVA and the various sagittal parameters showed some independent explanatory factors including the ΔC2-7 angle (r = - 0.25, p = 0.010), T1S-preoperative C2-7 angle (r = - 0.28, p = 0.004), postoperative O-C2 angle (r = 0.26, p = 0.007), ΔO-C2 angle (r = 0.37, p = 0.001). Multiple regression analysis revealed that ΔcSVA was associated with the T1S-preoperative C2-7 angle (ß = - 0.25, p = 0.034) and ΔO-C2 angle (ß = 0.32, p = 0.001). CONCLUSIONS: The imbalance between T1S and preoperative C2-7 angle influences the change of cSVA after cervical laminoplasty. If cSVA increases postoperatively, the O-C2 angle increases to compensate and maintain the horizontal gaze.

Optimal intermittent administration interval of parathyroid hormone 1-34 for bone morphogenetic protein-induced bone formation in a rat spinal fusion model.

INTRODUCTION: Both bone morphogenetic protein 2 (BMP-2) and teriparatide (parathyroid hormone [PTH] 1-34) are used to enhance bone healing. There is still no established opinion regarding the optimum dose and administration method. We investigated the optimal administration method for the combination of BMP-2 and PTH 1-34 in a rat spinal fusion model. METHODS: Group I was implanted with a control carrier. Groups II, III, and IV were implanted with a carrier containing 3 µg of recombinant human BMP-2 (rhBMP-2). In addition, following implantation, PTH 1-34 injections were administered to Group III thrice a week (total, 180 µg/kg/week) and Group IV six times a week (total, 180 µg/kg/week). The rats were euthanized after 8 weeks, and their spines were explanted; assessed by manual palpation, radiographs, and high-resolution micro-computed tomography (micro-CT); and subjected to histological analysis. Serum markers of bone metabolism were also analyzed. RESULTS: Manual palpation tests showed that the fusion rates in Groups III and IV were considerably higher than those in Group I. They also had higher radiographic scores than Group I and II. Micro-CT analysis revealed Tb.Th in the Group IV had higher values than that in the Group I, II, III with significant differences and Tb.Sp in the Group IV had lower values than that in the Group I, II, III with significant differences. Serum marker analysis revealed that Group IV had higher osteocalcin and lower tartrate-resistant acid phosphatase-5b than Group III. Histological analysis indicated that Group IV had enhanced trabecular bone structure. CONCLUSIONS: Frequent administration of PTH may be better in making thicker and strengthening the trabecular bone structure in newly formed bone in the rat spinal fusion model using insufficient BMP-2.

The fibrinogen levels on admission is a predictive marker of the contrast extravasation on enhanced computed tomography in sacral fracture.

ABSTRACT: Sacral fracture is the most frequent posterior injury among unstable pelvic ring fractures and is prone to massive hemorrhage and hemodynamic instability. Contrast extravasation (CE) on computed tomography (CT) is widely used as an indicator of significant arterial bleeding. However, while CE is effective to detect significant arterial bleeding but negative result cannot completely rule out massive bleeding. Therefore, additional factors help to compensate CE for the prediction of early hemodynamically unstable condition.We evaluated the risk factors that predict CE on enhanced computed CT in patients with sacral fractures. Patients were classified into 2 groups: CE positive on enhanced CT of the pelvis [CE(+)] and CE negative [CE(-)]. We compared age, sex, injury severity score (ISS), systolic blood pressure (sBP), type of sacral fracture based on Denis classification, platelet (PLT), base excess, lactate, prothrombin time-international normalized ratio, hemoglobin (Hb), activated partial thromboplastin time, D-dimer, and fibrinogen between the 2 groups.A total of 82 patients were treated for sacral fracture, of whom 69 patients were enrolled. There were 17 patients (10 men and 7 women) in CE(+) and 52 patients (28 men and 24 women) in CE(-). Age, ISS, and blood transfusion within 24 hours were significantly higher in the CE(+) group than in the CE(-) group (P = .023, P < .001, P < .001). sBP, Hb, PLT, fibrinogen were significantly lower in the CE(+) group than in the CE(-) group (P < .001, P < .001, P < .001, P < .001). D-dimer and lactate were higher in the CE(+) group than in the CE(-) group (P = .036, P < .001) with significant differences. On multivariate analysis, the level of fibrinogen was an independent predictor of CE(+). The area under the curve value for fibrinogen was 0.88, and the optimal cut-off value for prediction was 199 mg/dL.The fibrinogen levels on admission can predict contrast extravasation on enhanced CT in patients with sacral fractures. The optimal cut-off value of fibrinogen for CE(+) prediction in sacral fracture was 199 mg/dL. The use of fibrinogen to predict CE(+) could lead to prompt and effective treatment of active arterial hemorrhage in sacral fracture.

Successful treatment of left subclavian artery penetration due to ingestion of a safety pin by an elderly person.

BACKGROUND: Ingestion cases are increasing in elderly persons. Herein, we report a rare case of ingestion of a safety pin by an elderly person. CASE PRESENTATION: The patient was an 87-year-old bedridden woman who had fever with left pleural effusion. Chest X-ray revealed a foreign body, confirmed to be a safety pin, in the cervical esophagus. A contrast multidetector row computed tomography scan revealed that the opened safety pin penetrated the left subclavian artery, leading to the diagnosis of an esophageal foreign body penetrating the left subclavian artery. The safety pin was removed, and the subclavian artery aneurysm caused by the penetration was embolized by interventional radiology. After treatment, she was returned to the nursing home on postoperative day 8. CONCLUSION: Penetration by ingestion of a safety pin is rare; in this case, safe treatment was possible due to a team of certified specialist physicians and surgeons.

Analysis of reciprocal changes in upper cervical profiles after posterior spinal fusion with the simultaneous double rod rotation technique for adolescent idiopathic scoliosis.

BACKGROUND: The relationship between postoperative change of cervical lordotic alignment and restoration of thoracic kyphosis with adolescent idiopathic scoliosis (AIS) is still controversial. We investigated reciprocal changes in the sagittal profiles of the upper and middle-lower cervical spinal segments after posterior spinal fusion with the simultaneous double rod rotation technique (SDRRT) for AIS. HYPOTHESIS: Occiput-C2 and C2-C7 sagittal profiles of patients with AIS could change significantly after surgical adequate increase of thoracic kyphosis with SDRRT. PATIENTS AND METHODS: Twenty-seven consecutive patients with AIS treated with the SDRRT were retrospectively reviewed. We investigated the following parameters preoperatively, postoperatively, and at the 2-year follow-up: the Cobb angles of main thoracic curves; C7 sagittal vertical axis; thoracic kyphosis (TK) from T5 to T12; lumbar lordosis from L1 to S1; chin-brow vertical angle; McGregor's slope; occiput to C2 Cobb angle (O-C2angle); C2-C7 Cobb angle (C2-C7angle); T1-slope; and C2-C7 sagittal vertical axis. Additionally, the Scoliosis Research Society questionnaire was completed preoperatively and at the 2-year follow-up. Patients were categorized according to preoperative TK (T5-T12) into hypokyphotic (TK<20°) and normo-hyperkyphotic (TK≧20°) groups. To assess the effect of corrective surgery on sagittal profiles, we investigated correlations among the changes in sagittal parameters. RESULTS: The mean preoperative TK was 6.1±3.7° in the Hypokyphotic group and 23.5±4.7° in the Normo-hyperkyphotic group (p<0.001), which was significantly improved postoperatively (22.3±4.4° and 26.1±2.6°, respectively; p=0.02) and at the 2-year follow-up (23.0±6.3° and 26.8±5.0°, respectively; p=0.04). The mean preoperative C2-C7angle reflected kyphosis (7.4±9.8°) in the Hypokyphotic group, and, in contrast, lordosis (-8.8±6.8°) in the Normo-hyperkyphotic group (p<0.001), which improved toward greater lordosis postoperatively (-3.7±5.8° and -14.8±5.1°, respectively; p<0.001) and at the 2-year follow-up (-5.1±4.4° and -15.3±6.4°, respectively; p<0.001). On the other hand, the mean preoperative O-C2angle was -20.5±6.5° in the Hypokyphotic group and -13.1±2.8° in the Normo-hyperkyphotic group (p=0.002), which was significantly changed postoperatively (-12.6±6.4° and -7.7±4.3°, respectively; p=0.04) and at the 2-year follow-up (-13.1±6.3° and -7.9±4.3°, respectively; p=0.04). ΔC2-C7 was negatively correlated with ΔT5-T12 (r=-0.298) and ΔO-C2angle (r=-0.332). DISCUSSION: Lordotic reciprocal alignment changes in the C2-C7angle can occur after adequate restoration of TK. The O-C2angle compensates the C2-C7angle for a maintained horizontal gaze. O-C2 and C2-C7 sagittal profiles of patients with AIS changed significantly after corrective surgery with SDRRT. LEVEL OF EVIDENCE: IV, Case-series.

Analysis of the reciprocal changes in upper cervical profile and the risk factors for increasing cervical sagittal vertical axis after laminoplasty for ossification of the posterior longitudinal ligament of the cervical spine.

OBJECTIVE: The purpose of this study was to elucidate the reciprocal changes in the upper cervical profile and the risk factors for increasing cervical sagittal vertical axis (cSVA) after laminoplasty for ossification of the posterior longitudinal ligament (OPLL) of the cervical spine. PATIENTS AND METHODS: This retrospective study included thirty-nine consecutive patients (30 men and 9 women) with cervical OPLL who underwent cervical laminoplasty. We recorded the operative time, blood loss, Japanese Orthopaedic Association (JOA) score recovery rate. Radiological measurements were performed to analyze the following parameters: pre and 1- year postoperative chin-brow vertical angle (CBVA), McGregor's slope (McGS), occiput to C2 Cobb angle (O-C2 angle), C2-C7 Cobb angle (C2-C7 angle), T1-slope (T1S), C2-C7 sagittal vertical axis (cSVA) and calculated the change (Δ). Patients were divided into two groups according to ΔcSVA: positive (ΔcSVA ≥ 0) and negative (ΔcSVA < 0). RESULTS: Postoperative O-C2 angle (P = 0.028), ΔO-C2 angle (P = 0.019), ΔC2-C7 angle (P = 0.030) and T1S (P = 0.009) diff ;ered between the two groups. ΔcSVA showed a positive correlation with ΔO-C2 (R = 0.365, P = 0.022) and T1S (R = 0.472, P = 0.002). ΔO-C2 showed a positive correlation with T1S (R = 0.478, P = 0.002) and a negative correlation with ΔC2-C7 (R=-0.443, P = 0.005). ΔC2-C7 showed a negative correlation with T1S (R=-0.415, P = 0.009). Stepwise multiple linear regression analysis showed that ΔcSVA increased by 0.757 mm for each T1 slope and increased by 0.905 mm for each ΔMcGS. CONCLUSION: Increasing the lordosis in the O-C2 segment compensates for the loss of lordosis in the C2-C7 segment after cervical laminoplasty. Higher T1S is a risk factor for increasing cSVA after laminoplasty for OPLL of the cervical spine.

Analysis of computed tomography-based infra-acetabular morphometry to assess the feasibility of infra-acetabular screws.

INTRODUCTION: The number of pelvic fractures based on osteoporosis has been increasing. The infra-acetabular screw (IAS), which connected both osseous columns, is a safe method of screw placement going through the infra-acetabular corridor (IAC). However, the specifics of the anatomy of IAC have been far from completely understood, especially in the Asian population. The purpose of our study was to reveal the details of the IAC using computed tomography (CT) data. MATERIALS AND METHODS: Traumatized in-patients having pelvic CT scans from 2014 to 2016 were enrolled. Pediatric and adult patients with pelvic fractures and hip prostheses were excluded. The male/female ratio and distribution of patients' age were equalized manually; 40 male and 40 female patients were included. The IAC was measured on the plane of the inlet view (25° caudal) in multi-planar reconstructed CT images. MEASUREMENTS: infra-acetabular diameter (IAD), anterior-posterior length of the IAC (APL), length from the starting point of the IAC to the medial edge of the pelvis (LME), length from the starting point of the IAC to the top of the pubic symphysis (LPS), and tilting on inlet plate (TIP). RESULTS: Age was 59 ± 22 (mean ± SD). Height was 159 ± 11 cm, and body mass index (BMI) was 22.9 ± 4.1. IAD, APL, LME, LPS, and TIP was 4.0 ± 1.3 mm, 89.5 ± 7.1 mm, 8.7 ± 3.6 mm, 57.8 ± 4.8 mm, and 4.7 ± 5.2°, respectively. Over 20% of corridors (35 of 160) were not feasible for IAS placement, because of inadequate width (less than 3.0 mm). Nine corridors (5.6%) had curvature in IAC, which meant technically demanding to insert IAS. There was no difference in IAD between male and female patients, while APL, LME, LPS, and TIP had sex-related differences. CONCLUSIONS: Surgeons should pay attention to the fact that over 20% of IACs are not feasible for infra-acetabular screw placement even with the perfect reduction of fragments when treating acetabular fractures.

Fibrinogen level on admission is a predictive marker of the need for massive blood transfusion after pelvic fracture.

OBJECTIVE: This study aimed to evaluate the usefulness of coagulation biomarkers as predictors of the need for massive transfusion (MT) in patients with pelvic fractures. METHODS: Patients who were treated for pelvic fractures in our hospital were divided into 2 groups: MT and non-MT. MT was defined as the transfusion of packed red blood cells (PRBCs) ≧10 units caused by bleeding within 24 h after admission. We compared variables between two groups, including vital signs, the scoring system and blood sample test. Additionally, we performed a multiple logistic regression analysis and a receiver operating characteristic curve analysis to reveal which value was the most useful predictive marker for MT in patients with pelvic fracture. RESULTS: There were 22 patients in the MT group and 78 patients in the non-MT group. Patients in the MT group had significantly higher ISS than did those in the non-MT group. In contrast, the patients in the MT group had significantly lower RTS, TRISS Ps, sBP, Hb, lactate, BE, and Fbg levels. Lower sBP and Fbg levels were independent predictors for MT. The optimal cut-off values for sBP and Fbg levels were ≦109 mmHg and 193.0 mg/dL, respectively. CONCLUSIONS: The results of the study indicated that Fbg levels on admission can be an independent predictor of MT in patients with pelvic fractures. The optimal cut-off value of Fbg for MT prediction in this study was 193.0 mg/dL.

Cervical alignment after single-level anterior cervical corpectomy and fusion using autologous bone graft without spinal instrumentation for cervical pyogenic spondylitis.

BACKGROUND: Subsidence in anterior cervical corpectomy and fusion (ACCF) for cervical degenerative disease (CDD) are constantly observed during the postoperative course. Although kyphotic change of cervical alignment occurred frequently in cervical pyogenic spondylitis (CPS) postoperatively, studies on the postoperative change in segmental angle for CPS are limited. This study aimed to analyze cervical alignment after single-level ACCF using autologous bone graft without spinal instrumentation for CPS compared with that for CDD. METHODS: Six patients underwent single-level ACCF using autologous bone graft without spinal instrumentation for CPS. The control group included 18 age-matched patients who underwent single-level ACCF using autologous bone graft for CDD without spinal instrumentation for the same duration. Cervical and lateral plain radiographs and computed tomography scans were taken. The Frankel classification was used to assess the neurological status preoperatively, postoperatively, and at 2-year follow-up for CPS. RESULTS: At 2-year follow-up, the average segmental angle at the fusion level was - 12.2° ± 6.9° for CPS and - 5.2° ± 7.6° for CDD (p = 0.04). Changes in segmental angle at the fusion level were - 7.2 ± 9.0° for CPS and - 1.1° ± 7.1° for CDD (p = 0.02). At 2-year follow-up, the average anterior segmental fusion height was 23.4 ± 1.7 mm for CPS and 29.1 ± 5.1 mm for CDD (p < 0.001). At 2-year follow-up, bone fusion in the CPS group was classified as grade 5 (complete fusion) in 4 patients (66.7%) and grade 4 (probable fusion) in 2 (33.3%). In the CDD group, it was grade 5 in 13 patients (72.2%) and grade 4 in 5 patients (27.8%). Overall, both groups achieved 100% bone fusion rate. The Frankel classification in all CPS cases improved or leveled off. CONCLUSION: Progression of segmental kyphosis angle and subsidence of graft bone were observed postoperatively on all CPS cases. However, the neurological recovery and bone union were satisfactory.

Enhancement of the effects of intermittent parathyroid hormone (1-34) by bone morphogenetic protein in a rat femoral open fracture model.

BACKGROUND: Nonunion in cases of open fracture is common. Both bone morphogenetic protein 2 (BMP-2) and parathyroid hormone (PTH) have been used to enhance bone healing. We investigated the combination of BMP-2 and PTH and examined the effects on a rat model of open femoral fractures. METHODS: Group I (n = 11) was implanted with control carrier. Group II (n = 12) was implanted with carrier containing 1 µg of recombinant human BMP-2 (rhBMP-2). Group III (n = 12) was implanted with carrier alone, followed by injections of PTH 1-34. Group IV (n = 11) was implanted with carrier containing 1 µg of rhBMP-2, followed by injections of PTH 1-34. Group V (n = 11) was implanted with carrier containing 10 µg of rhBMP-2. Group VI (n = 11) was implanted with carrier containing 10 µg of rhBMP-2, followed by injections of PTH 1-34. Rats were euthanized after 8 weeks, and their fractured femurs were explanted and assessed by manual palpation, radiographs, micro-computerized tomography, and histological analysis. RESULTS: Manual palpation tests showed that the fusion rates of groups III (66.7%), IV (63.6%), V (81.8%), and VI (81.8%) were considerably higher than those of group I. Groups V and VI had higher radiographic scores compared to group I. Micro-CT analysis revealed enhanced bone marrow density expressed as bone volume/tissue volume in groups V (61.88 ± 3.16%) and VI (71.14 ± 3.89%) versus group I (58.26 ± 1.86%). A histological analysis indicated that group VI had enhanced remodeling. CONCLUSION: The combination of abundant rhBMP-2 and PTH enhanced bone healing and remodeling of newly formed bone in a rat femoral open fracture model.

The position of the spinal cord relative to the vertebrae in adolescent idiopathic scoliosis.

We aimed to clarify the position of the spinal cord relative to the vertebra in patients with Lenke type 1 adolescent idiopathic scoliosis (AIS). In all, 35 patients with Lenke type 1 AIS who underwent posterior spinal fusion using a pedicle screw construct and preoperative computed tomography (CT) after myelography were recruited. The following radiological parameters were measured on preoperative CT myelography: spinal cord-vertebral (SV) angle, entry-spinal cord distance (ESD), ESD-X, ESD-Y, spinal cord-pedicle (SP) angle, and rotation angle (RAsag). The SV and SP angles were the smallest at T9 level, followed by T8 and T7 levels, and tended to increase cranially and caudally. The ESD was the shortest at T9 level, followed by T8 and T10 levels. The ESD-X was the smallest at T9 level, followed by T8 level, while the ESD-Y was the smallest at T10 level, followed by T9 and T8 levels. Mean RAsag increased from T4 to T9 levels and decreased from T9 to T12 levels. The ESD was significantly negatively correlated to RAsag. Among all apical vertebrae, the SV and SP angles were negatively correlated to Cobb angle. The RAsag was positively correlated while the ESD was negatively correlated to the Cobb angle. The spinal cord is close to the vertebrae in the apical vertebral region and far from the vertebrae at the upper and lower thoracic vertebral levels in AIS. Therefore, the potential risk of spinal cord injury by pedicle screw is the highest in the apical vertebral region.

Effect of intraoperative position in single-level transforaminal lumbar interbody fusion at the L4/5 level on segmental and overall lumbar lordosis in patients with lumbar degenerative disease.

The purpose of this study was to investigate the effect of intraoperative positions in single-level (L4-5) transforaminal lumbar interbody fusion (TLIF) on segmental and overall lumbar lordosis (LL) in patients with lumbar degenerative disease. Thirty-eight consecutive patients who had undergone single-segment (L4-5) TLIF with 0° polyetheretherketone (PEEK) cage and pedicle screw fixation were evaluated. Twenty patients underwent surgery on the four-poster type frame with hip flexion at 30° (Group I) and 18 patients were operated on a Jackson spinal table to adjust their hip flexion to 0° (Group II). Preoperative standing, intraoperative prone, and postoperative standing lateral radiographs were obtained in each patient. The overall and segmental LL were analyzed according to the position in which the patients were placed for their operation and results compared between Groups I and II. Intraoperative intervertebral segmental LL at L4-5 and L5-S1 was increased in Group II than in Group I, whereas postoperative intervertebral segmental LL at L4-5 (fused level) was increased LL. In Group I intraoperative intervertebral segmental LL at L4-5 did not achieve sufficient lordosis, whereas postoperative intervertebral segmental LL at L3-4 was increased. The overall spinal alignment was unaffected by the decreased segmental LL in the fused level owing to the compensation of the upper adjacent segments. The more the hip was extended intraoperatively, the more the segmental lordosis increased in the lower lumbar spine. Thus, selecting the appropriate surgical table and hip position are very important. Underachievement of segmental lordosis leads to the acceleration of upper adjacent segment load.